Traditional birth attendants and folk midwifery

1. Introduction

Version followed: WHO definitions and positions on traditional birth attendants (WHO/UNFPA/UNICEF joint statement 1992; WHO/ICM/FIGO joint statement 2004); the National Aboriginal Council of Midwives (NACM, Canada) framework Indigenous Midwifery Knowledge and Skills: A Framework of Competencies (2019); Mexico's NOM-020-SSA3-2023 as reported in 2025; and, for the psychotherapist's own work, the DSM-5-TR Cultural Formulation Interview (CFI) and related cultural assessment tools.

What it is. This is not a psychotherapy. It is a family of living, community-based birth traditions: traditional birth attendants (TBAs) in many low- and middle-income countries, parteras tradicionales in Mexico and Latin America, and Indigenous midwives in Canada and elsewhere who are reclaiming birth for their communities. WHO defines a TBA as a "traditional, independent (of the health system), non-formally trained and community-based provider" of care in pregnancy, childbirth and the postnatal period [source: https://www.afro.who.int/sites/default/files/2017-06/mps%20skilled_attendant.pdf]. The psychotherapist does not practise any of these traditions. The therapist's job is to understand what the client's birth tradition means to them, to assess and treat perinatal distress in a culturally responsive way, and to work alongside the client's chosen birth attendant when the client wishes.

Who holds authority.

WHO and health systems. The 1992 WHO/UNFPA/UNICEF statement treated TBAs as an interim measure while professional care for all women was built up. It also said their caring, personal approach and their responsiveness to cultural and spiritual needs should be preserved [source: https://iris.who.int/items/0a0576b0-6944-4ee2-a5aa-bb922597062a]. The 2004 WHO/ICM/FIGO statement says TBAs "cannot replace the need for all women to have care from a skilled attendant" and that TBA training has not been shown to reduce maternal mortality. It recommends that TBAs act as advocates for skilled care, give social support during birth and link families with health services [source: https://www.afro.who.int/sites/default/files/2017-06/mps%20skilled_attendant.pdf].
Indigenous midwifery (Canada). NACM represents over 140 Indigenous midwives. It states that it is "not a governing or regulating body". Its framework is meant to be adapted by each community and Nation, with Elders and Knowledge Keepers as advisers and teachers. It "purposefully does not include any traditional teachings" [source: https://indigenousmidwifery.ca/wp-content/uploads/2019/07/NACM_CompetencyFramework_2019.pdf]. Training routes include apprenticeship with practising Inuit midwives, whose certification is recognised by the Quebec government (Tulattavik Health Centre, Kuujjuaq), and community-based programmes such as the Onkwehon:we Midwives Collective in Akwesasne [source: https://indigenousmidwifery.ca/wp-content/uploads/2019/11/NACM_Booklet_DiversePathways.pdf]. Traditional teachings and ceremony around birth belong to each community and are not described here.
Mexico. NOM-020-SSA3-2023 was published in the Diario Oficial in March 2025 and took effect on 1 September 2025. Federal authorities say it places midwifery in the first level of care. It allows a person giving birth to be accompanied by their "partera tradicional de confianza" (trusted traditional midwife) in midwifery houses and low-risk birth units. IMSS estimates about 21,597 parteras nationwide, of whom 6,527 are attached to IMSS-Bienestar. Partera organisations (for example Yolocihuacalli, Morada Violeta and Somos Tribu) say the standard does not distinguish traditional, autonomous and professional midwifery, ignores home birth and limits their autonomy. Parteras also report that civil registries do not accept their birth certificates and that some hospitals turn away women they refer [source: https://politica.expansion.mx/mexico/2025/08/17/parteria-tradicional-se-abre-paso-en-mexico].

How change happens (for the therapist's work). Perinatal distress is shaped by how a family and community understand pregnancy, birth and recovery. Change comes when the therapist (1) learns the client's own explanatory model and birth tradition, (2) separates culturally normal experiences from treatable illness, (3) connects the client with both the supports her tradition offers and the medical care she needs, and (4) helps her make sense of the birth, including loss, obstetric violence or forced separation from community [synthesis].

2. Framework

The traditions have no common phase model. The framework below organises the psychotherapist's own work across the perinatal timeline [synthesis]. Session counts are illustrative, not from a manual.

Phase	Goals	Typical format	Move on when
A. Engagement and cultural assessment	Build trust; core CFI; explanatory model; map birth attendants and family supports; screen for perinatal mood, anxiety, psychosis, violence and physical-safety risks	1-3 sessions of 50-60 min; an interpreter or cultural broker as needed; family or informant with consent	Shared definition of the problem; risks known; client has said whether and how the birth attendant should be involved
B. Formulation and collaboration plan	Cultural formulation; decide on referrals (obstetric, psychiatric, social care) and on contact with the partera, TBA or Indigenous midwife; written consent and confidentiality agreement	1 session, often with a partner or family member	Plan agreed; consent signed; roles clear
C. Perinatal treatment	Evidence-based treatment for depression, anxiety or trauma, adapted to the client's tradition; support for postpartum customs; family psychoeducation	Weekly or fortnightly, about 6-12 sessions; flexible around birth, possible evacuation and the postpartum period (home or phone sessions)	Symptoms falling; supports in place; client can name warning signs
D. Integrating the birth experience	Process the birth (including trauma, loss, obstetric violence, evacuation); restore continuity with family and community	2-6 sessions, usually from about 6-8 weeks postpartum or when the client is ready	Client can tell the story without being overwhelmed; meaning re-established
E. Closure and relapse planning	Plan for future pregnancies; maintain links with community and services	1-2 sessions; booster on request	Written plan; known route back

Risk overrides the phases. Suicidal thoughts, signs of postpartum psychosis, violence or a need for urgent obstetric care are handled at once, whatever the phase [synthesis]. WHO reports that almost 1 in 5 women have a mental health condition in pregnancy or the year after birth, and that 20% of women with perinatal mental health conditions have suicidal thoughts or self-harm [source: https://who.int/news/item/19-09-2022-launch-of-the-who-guide-for-integration-of-perinatal-mental-health].

CFI timing: the core CFI has 16 questions in four domains. The DSM-5 field trial found later interviews "required less time", but no time in minutes has been verified [uncertain] [source: https://edoc.unibas.ch/54937/].

3. Guiding principles

Work alongside, never practise. You do not give birth care, massage, herbs or ritual; you support the client and work with her chosen attendants [source: https://indigenousmidwifery.ca/wp-content/uploads/2019/07/NACM_CompetencyFramework_2019.pdf] [synthesis].
Authority lies with communities and their institutions. Indigenous midwifery knowledge is held and adapted locally, with Elders and Knowledge Keepers; national bodies such as NACM do not regulate it. Ask the client who her community recognises; do not certify or rank attendants yourself [source: https://indigenousmidwifery.ca/wp-content/uploads/2019/07/NACM_CompetencyFramework_2019.pdf].
Respect choice and support access to skilled care. WHO's position is that every woman needs a skilled attendant at birth. Traditional attendants can support, accompany and link. Hold both without forcing a choice [source: https://www.afro.who.int/sites/default/files/2017-06/mps%20skilled_attendant.pdf] [synthesis].
Cultural humility. Treat the client as the expert on her own tradition. Examine your own assumptions about "proper" birth [synthesis].
Attribute beliefs; neither endorse nor dismiss. Say "in your family, the 40 days mean..." rather than stating a belief as fact or calling it superstition [synthesis].
Cultural assessment supports, never replaces, diagnosis. The CFI informs clinical decisions but is not meant to be the only basis for a diagnosis [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf].
Avoid both pathologising and missing illness. Culturally normal postpartum customs and beliefs are not symptoms; perinatal depression and psychosis are not "just tradition" [synthesis].
Trauma-informed and anti-colonial. Colonial policy, forced evacuation and obstetric violence are part of many clients' birth histories; NACM's framework names work to "dismantle the historical and current colonial structures" [source: https://indigenousmidwifery.ca/wp-content/uploads/2019/07/NACM_CompetencyFramework_2019.pdf].
No advice on herbs, remedies or medicines. Ask about them, record them and route questions to the obstetric provider or prescriber; never advise starting, stopping or changing any medicine or remedy [synthesis].
Touch and physical practices. If the client describes massage or other body practices by an attendant, check that she was asked for consent before and during, could stop at any time, and that nothing sexual or genital happened outside clinical need. You never touch the client in this work [synthesis].
Consent and confidentiality for every contact with an attendant. Get written consent naming who, what and why [synthesis].
Safeguarding first. Intimate partner violence is common in perinatal populations; harm to a woman, fetus or newborn triggers your normal reporting duties. Never name minors in records shared outside your service [synthesis].
Do not appropriate. Do not ask to observe ceremonies or seek teachings; do not reproduce what a client shares about sacred practices [synthesis].

4. Intervention inventory

All interventions below are the psychotherapist's own. None of them involves giving birth care, body work, remedies or ceremony. Example language is illustrative unless quoted and cited.

4.1 Cultural self-examination before and during the work

Purpose / when: Before the first session and whenever you feel judgement about a client's birth choices (home birth, a partera, refusal of hospital).
Steps: (1) Write down your own assumptions about safe and proper birth and where they come from. (2) Note what you know about the client's tradition and how you know it (community source, scholarship by outsiders, media). (3) Name your reactions to TBAs or parteras, for example "unsafe" or "romantic". (4) Take both reactions to supervision or consultation. (5) Look again after any session where you felt pulled to persuade [synthesis].
Example language (illustrative, to yourself or a supervisor): "I notice I wanted her to choose the hospital before I knew why she chose the partera."
Watch for: Advice-giving about birth setting, curiosity that turns into extracting cultural detail, or idealising tradition so that you miss risk. It is working if you can describe the client's choice in her own terms [synthesis].

4.2 Core Cultural Formulation Interview adapted to the perinatal period

Purpose / when: Intake, and again when the picture changes (after birth, after a loss, after evacuation). The CFI clarifies the problem from the perspective of the person and her social network: what it means, possible sources of help and what she expects from services [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf].
Steps: Follow the four APA domains in your own words, keeping the perinatal frame. (1) Cultural definition of the problem (Q1-3): what she calls what is happening and what worries her most. (2) Perceived causes, context and support (Q4-10): her and her family's views of cause; stressors and supports, including the birth attendant; how her identity (Indigenous Nation, rural community, migrant status, faith) matters. (3) Self-coping and past help seeking (Q11-13): what she has done, who she consulted (partera, TBA, Indigenous midwife, Elder, faith leader, doctor), and barriers. (4) Current help seeking (Q14-16): what help she wants now and any concern about you as a clinician, such as racism or language barriers. The APA form may be reproduced by clinicians for use with their patients; modifying or translating it needs APA permission, so use the published form or work from it in your own words [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf].
Example language (illustrative): "People explain what happens in pregnancy and after birth in many different ways. How would you describe what you are going through, in your own words?" / "Who has been helping you through this pregnancy: family, a partera, a midwife, a doctor, anyone else?"
Watch for: Short or guarded answers about the birth attendant can signal fear of judgement or of being reported. Return to it later. It is working when the client corrects you or adds detail without being asked [synthesis].

4.3 Informant version with a family member

Purpose / when: When a mother, grandmother, partner or other relative organises postpartum care or makes birth decisions. The informant version (17 questions) is used with a family member or friend [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf].
Steps: (1) Get the client's consent and agree what may and may not be shared. (2) Interview the informant, alone or jointly as the client prefers. (3) Start with their relationship to the client. (4) Cover the same four domains from their viewpoint. (5) Compare accounts with the client privately [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf] [synthesis].
Example language (illustrative): "In your family, how is a new mother usually looked after in the weeks after birth? What would worry you if you saw it in her?"
Watch for: Coercion or control framed as tradition, or violence. If the client seems unable to speak freely with the relative present, see her alone [synthesis].

4.4 Explanatory model of perinatal distress (Kleinman)

Purpose / when: To learn how the client understands her distress so that treatment fits it. The questions come from Kleinman, Eisenberg and Good (1978) [source: https://www.cambridge.org/core/product/F99D9D36838A8207D377730DEB445F7B/core-reader].
Steps: Ask, in paraphrase: what she calls the problem; what caused it; why it started when it did (in pregnancy, at birth, after); what it does to her and how it works; how severe it is and how long it will last; what treatment she thinks she should get; the main problems it has caused; and what she fears most [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf]. Then explain your own model in plain words and negotiate a plan that fits both [synthesis]. Use the CFI Explanatory Model module for depth [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].
Example language (illustrative): "What do you think brought this on?" / "What does your partera, or your mother, say it is?" / "What are you most afraid could happen?"
Watch for: Explanations involving fright, cold, broken postpartum rules, spirits or envy. Record them as the client's model, not as delusions. It is working if the client agrees to a plan that respects her model and also addresses the symptoms [synthesis].

4.5 Supplementary modules for perinatal clients

Purpose / when: In-depth assessment, at the first evaluation or later in care. APA lists 12 modules [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].
Steps: Choose those that fit: Social Network (who helps during the postpartum period); Spirituality, Religion and Moral Traditions (meaning of birth, blessings, the client's faith); Cultural Identity; Coping and Help-Seeking (consultations with attendants); Immigrants and Refugees (loss of home birth customs, documentation); Caregivers (given to a caregiver, for example the grandmother providing postpartum care); Psychosocial Stressors; Patient-Clinician Relationship [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].
Example language (illustrative): "Where you grew up, who would have been with you in the weeks after the birth? Who is with you here?"
Watch for: Assessment fatigue in late pregnancy or the early postpartum period; spread modules over sessions. It is working if the formulation names concrete supports and gaps [synthesis].

4.6 Asking about traditional birth care without judgement

Purpose / when: At every perinatal assessment. Many clients do not mention a partera, TBA or traditional massage unless asked, especially after experiences of discrimination [synthesis].
Steps: (1) Normalise: say that many families combine traditional and medical care. (2) Ask who is accompanying the pregnancy and birth, and what they do in general terms. (3) Ask about any remedies, teas or medicines in general terms; record them for the obstetric provider without advising. (4) Ask about body practices in general terms and whether the client agreed to them and could say stop. (5) Ask what the client values about this care. (6) Do not ask for ceremonial details [synthesis].
Example language (illustrative): "Some women have a partera or a midwife from their community as well as a clinic. Is anyone like that helping you?" / "Is there anything you are taking, from the clinic or from home remedies, that your doctor or midwife should know about? I won't tell you to stop anything, but they can check it is safe with the rest of your care."
Watch for: Shame or fear of being reported. Signs of physical risk (see 4.9). It is working when the client brings the attendant's advice into sessions herself [synthesis].

4.7 Cultural concepts of distress and culturally normal experience

Purpose / when: When the client uses an idiom of distress, describes a culturally recognised illness, or reports experiences such as hearing an ancestor or receiving a message around the birth. DSM-5-TR defines cultural concepts of distress as including "idioms, explanations or perceived causes, and syndromes" [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf].
Steps: (1) Ask what the term means to her and her family, who usually recognises and treats it, and how it usually resolves. (2) Use concepts as the manual describes them; the DSM-5-TR list reported in a secondary source includes susto, nervios and ataque de nervios, relevant for many Latin American clients [source: https://www.unmc.edu/bhecn/_documents/dsm5tr_bw_6_slides_11_pages.pdf]. The exact DSM-5-TR list is [uncertain: not verified]. (3) Check whether the experience is shared and accepted by her community or faith; consult a cultural broker or community member with consent. (4) Screen in parallel for depression, anxiety, PTSD and psychosis. (5) For trance or possession presentations, note that ICD-11 trance disorder (6B62) and possession trance disorder (6B63) require that the state is involuntary and unwanted, and the DSM-5-TR dissociative trance category excludes trance that is a normal part of broadly accepted collective cultural or religious practice [source: https://www.findacode.com/icd-11/code-1807490186.html] [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574].
Example language (illustrative): "When you say you have susto since the birth, what does that mean for you? Who in your family would know what to do about it?"
Watch for: Using a cultural label to explain away severe depression or psychosis, or treating a shared belief as a symptom. Postpartum confusion, rapid mood swings, severe sleeplessness or beliefs about harming the baby need same-day psychiatric assessment, whatever the cultural frame [synthesis].

4.8 Perinatal mental-health screening and stepped referral

Purpose / when: At intake, in the third trimester and postpartum. Effective integration of perinatal mental health care, as WHO describes it, includes helping providers recognise symptoms and respond in ways suited to local and cultural context [source: https://who.int/news/item/19-09-2022-launch-of-the-who-guide-for-integration-of-perinatal-mental-health].
Steps: (1) Use a validated perinatal measure in the client's language, for example the Edinburgh Postnatal Depression Scale (EPDS); do not reproduce or improvise items. (2) Follow screening with a clinical interview. (3) Assess suicide and self-harm risk directly and at every contact if positive; use standard risk assessment and safety planning, including lethal-means counselling (safe storage and removal). (4) Ask about thoughts of harm to the baby and distinguish intrusive unwanted thoughts from intent. (5) Refer urgently for signs of postpartum psychosis or bipolar relapse. (6) Treat mild to moderate depression and anxiety with an evidence-based therapy adapted to the client's model [synthesis]. In one Kenyan project, trained TBAs screened pregnant women with the EPDS and referred at a score of 11 or more, with community health workers confirming diagnosis [source: https://old.aasciences.africa/news/engaging-traditional-birth-attendants-reduce-maternal-depression]. Cut-offs vary by language and population; use the one validated for your setting [synthesis].
Example language (illustrative): "Many women feel low or frightened in pregnancy or after birth. It is common and it can be treated. I ask everyone these questions." / "Sometimes when women feel this bad they think about ending their life. Has that happened to you?"
Watch for: Stigma ("a good mother does not feel this"), and minimising because the family is present. It is working when screening leads to a treatment the client accepts [synthesis].

4.9 Physical-safety screening and medical clearance

Purpose / when: Whenever the client describes traditional body practices, remedies or a plan to give birth outside facilities. You do not judge obstetric safety; you make sure an obstetric provider does [synthesis].
Steps: (1) Ask in general, non-explicit terms what body practices or remedies are being used, for example abdominal massage or teas. (2) Never give or endorse techniques, timings, temperatures or doses. (3) With consent, tell the client's obstetric provider or midwife. (4) Give clear information on urgent warning signs and how to reach emergency obstetric care, in her language. (5) Ask whether she agreed to any touch, could stop it, and whether anything felt sexual or violating [synthesis]. Published maternal-health training material describes traditional abdominal massage in prolonged labour as "an extremely harmful traditional practice" because it can cause uterine rupture, especially in women who have given birth before [source: https://content.oppia-mobile.org/mod/page/view.php?id=3810].
Example language (illustrative): "I am not the right person to say whether that is safe for you and the baby, but your midwife or doctor can. Would it be all right if we let them know?"
Watch for: Withdrawal if the client feels her attendant is being criticised. Frame the referral as adding safety, not replacing her attendant [synthesis].

4.10 Collaboration with the client's birth attendant

Purpose / when: When the client wants her partera, TBA or Indigenous midwife involved in her mental health care. WHO's 2004 statement sees TBAs as useful for social support, linking families with services and helping women follow up care [source: https://www.afro.who.int/sites/default/files/2017-06/mps%20skilled_attendant.pdf]. NACM's framework expects Indigenous midwives to consult and refer, collaborate with other providers and follow cultural protocol with traditional healers [source: https://indigenousmidwifery.ca/wp-content/uploads/2019/07/NACM_CompetencyFramework_2019.pdf].
Steps: (1) Ask the client whether, how and about what you may contact the attendant; get written consent. (2) Contact the attendant respectfully, as a colleague in the client's care; ask how they prefer to communicate. (3) Agree roles: who watches for which warning signs, who refers where, how to reach each other. (4) Share only what the client agreed. (5) Do not ask about traditional teachings or ceremony. (6) Review the arrangement with the client regularly [synthesis].
Evidence context: In Makueni County, Kenya, 20 trained TBAs screened 1,711 pregnant women, and women who received TBA-delivered psychosocial interventions adapted from mhGAP had fewer depressive symptoms at 3 and 6 months than women who were only referred; the community welcomed TBA involvement but roles needed clear definition and training [source: https://old.aasciences.africa/news/engaging-traditional-birth-attendants-reduce-maternal-depression]. For psychosis, collaborative care between traditional and faith healers and primary care in Nigeria and Ghana (COSIMPO; Gureje et al., The Lancet, 2020) reduced symptoms more than usual care, and harmful practices fell [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306]. In a Ghanaian prayer-camp trial (Ofori-Atta et al., Br J Psychiatry 212(1)), adding psychiatric medication lowered symptoms, but days in chains were not significantly reduced, so collaboration does not on its own end harmful practices [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial]. These trials concern healers rather than birth attendants; applying them here is [synthesis].
Example language (illustrative, to the attendant): "She told me how much your care means to her. I'm seeing her for the low mood since the birth. Could we agree how to reach each other if either of us is worried?"
Watch for: Breaches of confidentiality in small communities; the attendant feeling assessed; the client feeling outnumbered. It is working when information flows both ways and the client feels held by both [synthesis].

4.11 Supporting protective postpartum customs

Purpose / when: When the client's tradition includes a postpartum rest period with family support, such as la cuarentena, a roughly 40-day period in which the mother does not cook or clean while relatives take on the work [source: https://fmch.bmj.com/content/fmch/9/3/e000504.full.pdf].
Steps: (1) Ask what the custom would look like in her family and what is possible now. (2) Identify gaps, for example migration away from female relatives. (3) Problem-solve substitutes the client finds acceptable: a faith community, friends, a doula, paid help. (4) Separate the supportive core (rest, help, company) from any part she experiences as restrictive or that her medical team is concerned about, and refer the latter to the obstetric provider [synthesis]. Sampson et al. (2021) note that these customs are not always available in the US and that a mother without family support may be more vulnerable [source: https://fmch.bmj.com/content/fmch/9/3/e000504.full.pdf].
Example language (illustrative): "In your family, who would normally be with you during the 40 days? Who could step into that role here?"
Watch for: Guilt when the custom cannot be followed, and the belief, found in Sampson et al.'s focus groups, that a depressed mother must lack family help, which can hide symptoms in well-supported women [source: https://fmch.bmj.com/content/fmch/9/3/e000504.full.pdf].

4.12 Family and partner psychoeducation

Purpose / when: When family norms hide symptoms or discourage help seeking. Sampson et al. recommend family-focused education, teaching partners to recognise postpartum depression and explaining the range from baby blues to severe depression [source: https://fmch.bmj.com/content/fmch/9/3/e000504.full.pdf].
Steps: (1) With consent, invite the people the client names. (2) Explain perinatal mood conditions in plain words linked to her explanatory model. (3) Describe what is normal tiredness and sadness and what needs help. (4) Agree who notices what and whom they call. (5) Include the attendant if the client wishes [synthesis].
Example language (illustrative): "Feeling tearful for a few days after birth is common. If she is still very low after two weeks, can't sleep even when the baby sleeps, or talks about not wanting to live, she needs help that day."
Watch for: The partner as a source of danger: see 4.15. It is working when relatives describe warning signs in their own words [synthesis].

4.13 Integrating the birth experience, including trauma and obstetric violence

Purpose / when: After a frightening, violent or disappointing birth, a loss, an emergency transfer, or mistreatment in a facility. In Mexico, INEGI data cited in 2025 show 7.8 million women aged 15-49 reported some form of violence during births or caesareans in hospitals between 2016 and 2021 [source: https://politica.expansion.mx/mexico/2025/08/17/parteria-tradicional-se-abre-paso-en-mexico].
Steps: (1) Assess for PTSD and depression. (2) Let the client tell the birth story at her pace, with grounding available. (3) Name mistreatment as mistreatment when she describes it. (4) Explore meanings drawn from her tradition (for example how her community understands a difficult birth or a loss) and the comfort it offers, without endorsing or disputing them. (5) Use an evidence-based trauma therapy when PTSD is present, with consent, contraindication checks (active psychosis, acute suicidality, ongoing violence) and the right to pause. (6) Support complaints or advocacy if she wants them [synthesis].
Example language (illustrative): "You can stop at any moment. Tell me about the birth from wherever you'd like to start." / "What you describe was not right. You deserved to be asked before anyone touched you."
Watch for: Dissociation, flooding, shame, and fear of future births or of facilities. It is working when the story becomes tellable and avoidance of care decreases [synthesis].

4.14 Birth evacuation, colonial history and community birth

Purpose / when: With Indigenous clients from northern and remote communities in Canada who must leave home to give birth, or whose families carry that history. Amundsen and Kent-Wilkinson (2020) describe "forced prenatal evacuation" under Health Canada policy, link it to mental health issues, emotional distress and the loss of traditional birth practices, and call for culturally safe care [source: https://journalhosting.ucalgary.ca/index.php/ijnss/article/view/71469]. NACM describes community-based midwifery-led births as "central to healing and wellbeing" [source: https://indigenousmidwifery.ca/wp-content/uploads/2019/11/NACM_Booklet_DiversePathways.pdf].
Steps: (1) Before evacuation, plan with the client for isolation, contact with family, and who will accompany her. (2) Offer remote sessions that continue through evacuation and return. (3) Ask whether she wants to connect with Indigenous midwives, Elders or community health workers, and help her reach them through community pathways; do not arrange ceremony yourself. (4) Explore intergenerational experiences of birth, residential schools and services, at her pace. (5) After return, support reconnection with family and community [synthesis].
Example language (illustrative): "Being sent away to give birth is hard, and your family has its own history with that. What would help you feel connected while you're away?"
Watch for: Distrust of services as a reasonable response to history, not "resistance"; grief over a birth away from home. It is working when the client keeps contact and has supports in both places [synthesis].

4.15 Safeguarding

Purpose / when: Throughout. In the Kenyan TBA project, 73% of women confirmed as depressed reported some form of intimate partner violence [source: https://old.aasciences.africa/news/engaging-traditional-birth-attendants-reduce-maternal-depression].
Steps: (1) Ask about violence and control privately, at every phase. (2) Ask about delays in reaching urgent obstetric or newborn care and why. (3) Distinguish customs that a family or community practises safely from harm presented as tradition, and do not treat unfamiliar customs as abuse in themselves; consult a cultural broker and your safeguarding lead. (4) Follow your jurisdiction's reporting duties for harm to adults at risk, the unborn child where the law covers it, and the newborn or other children. (5) Record minors by role, not name, in any shared notes. (6) Where the client is herself a minor, assess consent and assent separately and involve guardians as law and her safety allow [synthesis].
Example language (illustrative): "I ask everyone this. Does anyone at home hurt you, frighten you or stop you getting care?"
Watch for: Partners insisting on attending every session; the client's fear that disclosure will lead to her baby being removed. Explain your duties honestly at the start [synthesis].

4.16 Interpreters and cultural brokers

Purpose / when: When the client's first language differs from yours, or when you need help understanding a community norm. The CFI's last question concerns barriers in the clinician-client relationship, including language and perceived racism [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf].
Steps: (1) Use trained interpreters, not relatives, for clinical content. (2) Check the interpreter is acceptable to the client given small-community and gender issues. (3) Brief the interpreter on perinatal terms and confidentiality. (4) With consent, consult a cultural broker about community views of birth practices, without identifying the client. (5) Debrief after emotionally hard sessions [synthesis].
Example language (illustrative): "Is it all right for you to talk about the birth with this interpreter here? If not, we can find someone else."
Watch for: The interpreter softening or editing what the client says; the cultural broker speaking for the client. It is working when the client's own words come through [synthesis].

4.17 Helping the client navigate systems

Purpose / when: When the client meets barriers because she used a traditional attendant. In Mexico, parteras report that civil registries do not accept their birth certificates and that hospitals sometimes turn away women they refer [source: https://politica.expansion.mx/mexico/2025/08/17/parteria-tradicional-se-abre-paso-en-mexico].
Steps: (1) Identify practical stressors (birth registration, transfer to hospital, insurance or documentation). (2) Link the client with social work, legal aid or patient advocacy. (3) With consent, write letters supporting her access to care. (4) Help her plan for emergency transfer so that the attendant and the hospital know the route in advance [synthesis].
Example language (illustrative): "Let's work out who you would call and where you would go if you or the baby needed a hospital quickly."
Watch for: Helplessness and anger about discrimination; validate these and turn them into small steps. It is working when practical stress falls [synthesis].

5. Handling problems

The sources cited here do not address therapy problems in this context; the guidance below is [synthesis] unless a source is given.

The client will not talk about her partera or TBA. Likely fear of judgement or of being reported. Explain that you do not report people for using traditional care, state your real safeguarding limits, and return to the topic later with curiosity about what she values. Do not push.
The client asks your opinion of a remedy, massage or home birth. Do not give one. Say it is outside your role, ask what she has been told, and with consent bring the question to her obstetric provider or prescriber. Never advise starting or stopping any medicine or remedy.
Conflict between the attendant's advice and obstetric advice. Do not take sides. Help the client list each view, what she fears and what she values, and support a joint conversation if she wants one. If there are urgent warning signs, say plainly that she needs emergency obstetric care now.
Family insists that distress is spiritual, or that tradition forbids therapy. Use the explanatory model: accept the family's frame as theirs, and propose that therapy can work alongside the remedies they trust. If the client is at risk, safety comes first.
Suspected postpartum psychosis or acute suicidality. Arrange same-day psychiatric assessment; do not wait for cultural clarification. Involve the family and attendant as the client consents or as safety requires.
Overwhelm during birth-trauma work. Pause, ground, shorten exposure and return to stabilisation. Delay trauma processing during active newborn crises or ongoing violence.
Non-attendance in late pregnancy or the newborn period. Expect it. Offer phone, video or home visits where your service allows, shorter sessions, and a baby-in-the-room option.
Rupture after you ask about traditional care or mention safeguarding. Name it, apologise for any sense of judgement, explain why you asked, and ask what would help her feel respected.
The client asks you to arrange ceremony, find an Elder or attend a birth ritual. Explain that these belong to her community. Help her identify legitimate community pathways (her Nation's health services, Indigenous midwives, community organisations), and do not take part yourself.
The therapist's own pull to rescue or to romanticise. Bring it to supervision. Check against the principle of working alongside, not practising, and against the client's stated goals.
Attendant or community member asks for clinical information. Share only what written consent covers; in small communities, agree in advance what may be said and to whom.
Possible harm by an attendant (for example coerced or sexualised touch, or delay of urgent care). Support the client, assess risk, follow your reporting duties and inform the client what you are doing. Avoid generalising to all attendants in the tradition.
Distrust from colonial or obstetric-violence history. Treat it as information, not resistance. Be transparent about records, reporting and who will see what; let the client set the pace [source: https://journalhosting.ucalgary.ca/index.php/ijnss/article/view/71469] [synthesis].

Sources

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